Cognitive behaviour therapy for whiplash injury (?)

1. Cognitive behaviour therapy for whiplash injury (?) Justin Kenardy, Rachel Dunne, Michele Sterling CONROD, The University of Qld ,

2. What is Posttraumatic Stress Disorder (PTSD)? • Traumatic event + Reaction • Symptoms • Reexperiencing • Avoidance • Hyperarousal • Duration > 1 mo. (< 1 mo Acute Stress Disorder) • Functional impairment • Diagnosis vs symptoms (subclinical)

3. Event vs injury related distress

4. PTSD & Whiplash • Higher rates of PTSD in Whiplash patients1,2,3. • Overlapping epidemiologic and clinical features1 • May involve stress system dysregulation4 • Cortisol abnormalities in both Whiplash4,5 and PTSD6 • Sensory hypersensitivity (lower pain thresholds)7 • impaired sensory nervous system functioning 7 • McLean, Clauw, Abelson & Liberzon, 2005 • Buitenhuis et al , 2006 • Sullivan, et al., 2009 • Wessa, Rohleder, Kirschbaum & Flor, 2006 • Gaab, Baumann, Budnoik, Gmunder, Hottinger, Ehlert, 2005 • Liberzon, Abelson, Flagel, Raz & Young, 1999 • Sterling and Kenardy, 2006

5. PTSD and WADSelf-reported Pain and Disability * = p < .05; ** = p < .01.

6. WAD and PTSD: SF-36Disability and Quality of Life *= p < .01; ** = p < .05.

7. Whiplash Recovery vs Chronicity • Higher initial pain and disability1, 2 • Posttraumatic stress reaction1, 3, 4, 5 • Cold hyperalgesia1, 3 • Older age1,2 • Sterling, Jull, Vicenzio, Kenardy & Darnell, 2005 • Buitenhuis, Spanjer, Fidler, 2003 • Sterling, Kenardy, Jull & Vicenzio, 2003 • Buitenhuis et al, 2006 • Jaspers, 1998

8. Study 1 • Aim • Investigate the effect of co-morbid PTSD on physiological arousal and sensitivity to induced pain in patients with chronic Whiplash. • Participants (N = 72) • 17-65yrs (M = 35), 65% female • Chronic Whiplash to Grade 3 (3mths – 5yrs, M = 2.5yrs) • Exclusions: fractures, head injury, history of neck pain.

9. Measures • Neck Pain and Disability (NDI) • Neuropathic pain (S-LANSS) Assessment of PTSD • Posttraumatic Stress Diagnostic Scale (PDS) • Structured Clinical Interview for DSM (SCID) • Allows screening out of symptoms attributable to injury/environment. “Challenge” assessment • Derive individual recall of trauma events • Assess pre- and post-trauma cue • Physiological arousal, pain sensitivity, affect.

10. Design and hypotheses2x2 Mixed Experimental design ↑ Arousal and negative affect PTSD ↓ Pain threshold No PTSD Minimal changes in arousal, affect and pain. Trauma cue exposure Baseline Post-exposure (n = 33) PTSD – higher baseline arousal and negative affect and lower pain threshold. (n = 39) Between groups = PTSD, No PTSD Repeated Measures = Baseline and Post-Exposure

11. Arousal MeasuresThe Lifeshirt System Heart rate Blood pressure Respiratory Rate Skin Conductance Skin Temperature

12. Sensory Pain Thresholds • Pressure • - Local - cervical spine • Remote - Median nerve • & tibialis anterior • Heat and Cold - cervical spine

13. Results Negative Affect • PTSD group reported more negative affect across time. • Increase in negative affect for both groups after trauma-cue • Stronger increases in PTSD group compared to the No PTSD group. • Similar results for self-reported Pain on NRS.

14. Results Arousal HeartRate Blood Pressure • - PTSD group higher arousal (HR and BP) across time. • Increased arousal in both groups after trauma-cue. • Significantly greater increases in PTSD group compared to No PTSD.

15. Results Pressure Thresholds C2 • Cervical Spine • PTSD group lower across time. • Further decrease in PTSD group after trauma-cue. • Remote Sites • PTSD group lower across time • Minimal changes after trauma-cue.

16. Results Thermal Pain Thresholds • PTSD group had lower thresholds to cold and heat across time. • Significant decrease in cold threshold for PTSD after trauma cue. • Minimal change in heat thresholds after trauma-cue.

17. Summary • PTSD in WAD patients is associated with: • greater negative affect and physiological arousal. • Lower sensory pain thresholds • Further decreases in cold and cervical pressure thresholds after trauma-cues.

18. So, what can we do about it? • Can we treat PTSD in patients with WAD?

19. Trauma focused CBT has been shown to have moderate effectiveness in treating PTSD within chronic pain samples.1,2,3 • A case study has shown CBT aimed at PTSD within Whiplash resulted in improved chronic pain management and coping.4 • Back, Coffey, Foy, Keane & Blanchard, 2009 • Shipherd , Back, Hamblen, Lackner & Freeman., 2003 • Taylor et al., 2001 • Jaspers, 1998

20. Hypotheses • CBT for PTSD will result in: • reduced PTSD symptoms • reduced negative affect and physiological arousal to trauma-cues • improved functional disability and quality of life • Previous research indicates minimal impact of CBT for PTSD on pain measures.

21. Assessed as eligible from Study 1 (PTSD and WAD) (n = 33) Did not consent to participate (n = 7) 4 due to time, 2 due to transport and 1 was already receiving psych treatment Consented to participate – Random allocation (n = 26) Allocated to TREAT condition (n = 13) Allocated to WL condition (n = 13) Analysed at post (n = 12) Discontinued treatment (n =1) due to moving interstate Analysed at post (n = 11) Lost to follow up (n =2) 1 declined to participate further and 1 unable to contact Analysed at 6-mo follow-up (n = 11) Discontinued participation (n = 1) 1 participant completed questionnaire data but not physical measures

22. Treatment Protocol • 10 weekly sessions with clinical psychologist • CBT for PTSD based on Bryant program • Treatment components included: • Relaxation training (e.g. deep breathing, PMR) • Cognitive restructuring • Imaginal Exposure (recalling accident with thoughts, physical sensations and emotions) • Invivo Exposure (fear hierachy of avoided accident related activities, people and places) • Relapse prevention

23. Baseline comparisons • Participants in Treatment (n=13) and WL (n=13) were comparable on: • demographic and accident variable • initial and current WAD symptoms. • trauma symptoms (SCID, PDS and IES-R) • depression, anxiety and stress (DASS) • Fear of re-injury (TSK) • Neck pain intensity (NRS) and disability (NDI) • Medication use

24. PTSD Diagnosis% no longer meeting SCID criteria for PTSD • Sig more people in TREAT group (8/13) no longer met PTSD criteria at post-assessment, compared WL (1/13). • Treatment effects were maintained at 6mo FU with 9/13 no longer meeting criteria for PTSD.

25. Neck Disability Index • TREAT group showed significantly greater improvement in neck disability post-treatment, compared to WL group . • Improvements were maintained at 6month follow-up.

26. Physiological Arousal HR - Overall trend (p=.08) for greater reductions in baseline arousal measures (BP and HR) in TREAT group compared to WL. - Reduced physiological reactivity to the trauma cue (comparison of difference scores pre-post cue) in TREAT group compared to WL group for all 3 arousal measures.

27. Sensory Pain Thresholds • Minimal changes between groups or over time for PPTs (remote or local) or HPT. • Trend (p=.07) for greater reductions in Cold Thresholds for TREAT compared to WL. • Also trend (p=.08) for reduced Cold thresholds in TREAT Group from pre-6mo. Cold

28. Sensory Pain and Trauma cue • The trauma cue was found to have less impact in TREAT group compared to WL for Cold pain at post-treatment and this was maintained at 6mo.

29. Implications and Future Research Directions • CBT was found to be effective in treating PTSD within chronic WAD. • Need to replicate in acute WAD. • CBT for PTSD had impact on pain thresholds. • Future research on treatment for this comorbidity should look at using CBT first to reduce PTSD symptoms and then focus on physical therapy for WAD symptoms.

30. Early intervention: Screen and Treat • Identify high risk of PTSD using a screen. • Provide information-based intervention • Confirm with clinical assessment. • If ASD/PTSD comorbid with WAD pre-treat with Trauma-Focussed CBT +1 mo., then intervene with WAD.